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HomeMy WebLinkAbout0053 GREENWOOD AVENUE�y � � ,, Town of Barnstable *Permit# Expires 6 months rom issue d e Regulatory Services Fee - SPABLE, • _ �41t Thomas F.Geiler,Director9. . A : 9 _ Building Division - - �cS'T Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION ' RESIDENTIAL ONLY . •Not Valid without Red X-Press Imprint Map/parcel NumberjPp94(,/KA 1-.3 z _ Property Address " 7. ,Residential Value of Work ��S .O� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name �i�,. �j •' `gin Telephone Number Home Improvement Contractor License#(if applicable) .16 �2 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance, Check one: ❑ I am a sole proprietor ❑ I the Homeowner I have Worker's Compensation Insurance Insurance Company Name A / AA.1,4 UAL,6 I— Ajr Workman's Comp.Policy# )'6 0 .Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box)- e �Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)it of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required... Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt,compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is equired. SIGNATURE: t .- Q:\WPFILESTORMS\building permit forms\EXPRESS.doG Revised 053012 r CERTIFICATE OF LIABILITY INSURANCE DATE07 os2012'' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of-such endorsement(s). PRODUCER CONTACT Oxford Insurance Agency N"AME` PHONE FAX P 0 Box 370 .. (A/C. No. Ext): (A/C. No): E-NAIL Oxford MA 01540 ADDRESS: , PRODUCER - CUSTOMER ID#. INSURED(S) AFFORDING COVERAGE NAIC$ INSURED - INSURER A: A.I.M. Mutual Insurance Cc - 33758 Libero Molinari INSURER B: - dba Molinari Home Improvement INSURER 11 Sheep Pasture Way 114SURER D: East Sandwich, MA 02537 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN'REDUCED BY PAID CLAIMS. we POLICY EFF POLICY EXP L� TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY - - EACH OCCVRANCE. $ ❑COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ , PREMISES(Ea.occarrenee) ❑❑CLAIMS MADE OCCUR - ❑ NffiD EXP (Any one person) $ PERSONAL c ADV INJVRY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES ER: - []POLICY ❑PROJECT aLOC PRODUCTS-COMP/OP AGO $ AUTOMOBILE LIABILITY, - COMBINED SINGLE LIMIT (ea accident) 5 ❑ANY AUTO ❑ALL OWNED AUTOS BODILY INJURY (per Person) 9 ❑SCHEDULED AUTOS - - BODILY INJURY(per accident) 9 PROPERTY DAMAGE HIRED AUTOS (Per aoeidont) $ ❑NON-OWNED'AUTOS _ $ UMBRELLA LIAB ❑ OCCUR EACH OCCURRENCE $ [:]EXCESS'LIAB CLAIMS MADE AGGREGATE $ ❑DEDUCTIBLE - $ RETENTION $ 9 WORKERS COMPENSATION ® xrmtc araru- �H_ AND EMPLOYEES LIABILITY r Lxxxra THE PROPRIETOR/PARTNERS/ - E.L..EACH ACCIDENT $ 100,000 A EXECUTIVE OFFICERS ARE �j ❑ incl ® exci 7008113012012 05/21/2012 05/21/2013 E.L. DISEASE -POLICY LIMIT $ 500,000 E.L. DISEASE -EA EMPLOYEE $ 100,000 COMMENTS /DESCRIPTION OF OPERATIONS OR LOCATIONS: - LIBERO MOLINARI IS NOT COVERED BY THE WORKERS!COMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF BARNSTA3LE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE.DELIVERED IN ACCORDANCE WITH THE 200 MAIN STREET - - .POLICY PROVISIONS. HYANNIS MA 02601 e AUTHORIZED REPRESENTATIVE Page No. of Pages. 1 t MOLINARI HOME IMPROVEMENTS 93 THORNTON DRIVE HYANNIS, MASSACHUSETTS 02601 Sn Phone/Fax (508) 888-3750 Sandwich P" R OP, Phone/Fax (508) 771-5266 Hyannis . ., -v.. PHONE DATE TO 17_ .1 F_A r ?. /l7Y1 ' 1 i ......,.. . MOC7 TI II'1V q/\OOt^T "' JOB NAME/LOCATION - - �l1M ,^ENTRn1 CT STnl,l(.`..u.Tnh.l ivi/\ ,'l'7r17,? .. H\//\hIhITC h/ir1 . JOB NUMBER JOB PHONE We hereby submit specifications and estimates for: CIC`_Onr'iF= rKIT'TOC On('IC' _lit CTDTO nC'r C'VTC'rT\Ir,. OnnCTN(:.'. .. t2 ThICT/\I 1 MET.r\1 rIOT.O C'rl( C' lt,3 TN Tn1 1 NEW lIrhIT C)Tnr rI /\QWTN( :ff4 TNST^.I I 1 C,1 R C7rI T T^.D O/ nco +tom CHF(`K C'I +)CHThlr` (,.OnlIfir, r1WTN1hIrV r^;hlr) r'nl (KITC'DC'I /\`^1.,1 vWw r 0 r-- Kir(''rQQ/\DV - :H•ti ThIM•T^.1 I 70 VO P%Or'11J.CT C!HTKInI C'c,-• ( r'('11 nO Tr) Or Cwl C'r'Tri7i M?V nWKIr'0 7 T H 0 R nI Ir`H r•1 E/\N I.)P nr Al I r)C'.DOTC DCI 0T7h1 G Tn Tf.IC f1 R.n 1vl C' I.InDIt +1•G C"M rl r-.T pnnc POI:./\ Tf,1�_IT^.I I C.I /\CTnr1 rV OnnC-TKir.. 1,4^T.rc)T/\I 119 1NST^.1 1 OTr'GE VEE IT nhl M^ThI Onni: /\I.Ir1 G"`nr--TT itrhlTC 411.41 42 .C'OC f.lE(`F`C`S/\DV r :k TC'hl V'C-^D I..InDk'M/\hl4''t�ITO 11(�D/\NTCC" 'i- MC-la4 FF •''l THTDT•V YEnR I..nRP,'"tNT'V nhl C,f•.fThfr`I rC - - v ,, .: .: n. : : ...:. ...:.....i . ...:...:... ...rill IV ThIC11017r, 6.1nDllMChIC r`nMOChIC/\TTnN /\hCh I TPtQTI TR"\•' TNCI L0/1f:1r1C" - NQ 2)T(DIP0019 hereby to furnish material and labor—complete in accordance with the above spe ,fications,for the sum of: r'',',!r- 7LLC]L Ir•/•h r^. r'"'1'•� � - _ v :.- , .. ..... ....: :: :_. ...., . , „_•:,:_.,,,._,_• : ::.:. . ....... . _ dollars($ Payment to be made as follows: 7�f,C� Ur;CS�3 ' nN - flnl TO BE (l/\Th I'IOnhl r nh(iAa—KIr,rMrkiT nr T41� PYRn1r;C I,.,Ir)0V , L c G^.I /\if( G ' Tn C :. :,. , . ...,. I1r' Tr I Iflrihl ( nMOI CTTnhI 4 C'4 0-C All material is guaranteed to be as specified. All work to be completed in a professional - - manner according to standard practices. Any alteration or deviation from above specifica- Authorized Lions involving extra costs will be executed only upon written orders,and will become an- Signature extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays.beyond our control. Owner.to carry fire,tornado,and other necessary insurance.Our Note:This proposal may be workes are fully covered by Worker's Compensation.Insurance. withdrawn by us if no ccepted within 1 n \`C days. Y ���������� ®� ��®�®�a� —The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized Signatur to do the work as specified. Pay ent will be made as outlined above. Signat (Date of Acceptance: ' = NIassachusctts= t7ep:utmcnt of Pubiic S tfctN Board of Building Replatians and Stand u d Construction Supervisor License. License: .CS 40124 :IBERO J MOLINARI. `t 11 SNEER PASTURE,WAY E,SANDWICH MA 0253.7 `Expiration: 3/29/2013 Jumniissioner" Tr#: 12618 ones merr�ffairs r�lG1 oeulatio�eL� License or registration valid for individul use onl . � Office of Consumer Affairs&Business Regulation g Y OME IMPROVEMENT CONTRACTOR ibefore the expiration date. If found return to: egistration: ,102322 Type: Office of Consumer Affairs and Business Regulation xpiratiow_7/1/2014 DBA , 10 Park Plaza-Suite 5170. Boston,NIA 02116 MOLI ARI ROOFING `- ��' Libero Molinari ,� r 11 SHEEP PASTURE WAY EAST SANDWICH, MA 02537 Undersecretary Not valid without signature The Commonwealth of Massachn setts rtirrerit©f lndustrial ccidents - Office of Investigations 600 Washington Street .Boston,MA 02111 N•'/VtstmasmgG►1dJa. Workers' Compensation Insurance Affidavit- Biers/Conbmcbnrs(Flect6cians/Plumbers Applicant Information /J �d Please Plrint Ix�b}y Name( d�u �'// 7 �Cl i/-4aw e Address- CitylState/Zip_ Phone 1 PF 6 0 6 -7 y5l Are you an employer? I Cheek the appropriate boa: T r 4_ am.a. conractoan project(required): l�I am a employer with. ❑ t id I Type of roect employees(fall andlor part-time}:* have hired the sub-contractors 6. ❑New construction 2-❑ I am a sole proprietor or partner- listed on attached sheet. 7- ❑Remodeling ship and have no employees These sob-contractors have g- ❑Demolition working for me in any capacity employees and have wodcess' 9: ❑Building addition [No worbuk eomp-insurance comp.insurazp r- e -]. ❑ re We a a corporation and its 14-❑Electrical repairs or actions 3_❑ Lam a ham�doing. ll:wbik officers have exercised dmW 11-0 P g repairs or additions. myself [No workers'"CV, rig of h exemption per MGL 12. of repairs �in� rereTm-e&]S C. 152, §1(4] and we have no employees.[No workers'. 13..0''Other comp:insuzame required] •Ainy applicanR.cut checks box#1 must also fill out the section behtw showing thou wor kerV cbmpensatian.policy infnrmation- A who subatait this affidin4 indicating they are doing 0 work and du hire outside contractors aa�ztst submit a near aMdaeit indicating sack lContracctars thst check this boat must attached an additional sheet showing the nmme of the sab-cantlma s and state whether or=those entities have employees. If the.subtanttacto¢s hare employees,dtey moist p—idie:t*ttr workers'comp-policy ntnnher- lam an employer tliat rs pm ding mvrken'coerp msad",insurance for my omplajwas. Below is the policy and jab site, information: Insurance Company Name: A /M INA t11 CIO t. / IV's C- o Policy#or Self-ins-Ile.#: 7 U"o�r/ t 3 0/ V Expiration Date: Job Site Address::' �} �i�-o�+r .c.i City/Stafe/Zip: ;��4// 7 Attach a copy of the workers'compensation policy declaration page(showing the policy number.and expiation date). Failure to secure coverage as required'under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to$1,500-00 armor one-year imprisonment,as well as civil penalties in the form of a STOP WORT ORDER and a fine ofup to$250-00 a day against the violator- Be advised that a copy of this statement may be fided to the Office of Investigations of the DIA for insurance coverage verifkaticid_. I do hereby catW . thepains andponalties ofperjuty that the information proW&d above fs true and correct Sienatrio: A4- ?ate: 1 Phone Official use only.: Do not write in this area,tb be completed by city or town o,Qrciat City or Town. PermitUcense# Issuing Authority'(circle one): 1.hoard of Health y.Bidding Department 3.C itty/rown Clerk 4.,Electrical Inspector 5.Plumbing Inspector 6.Other: Contact Person: Phone.#: 6 Assessor's 'map a'nd lot 'number ...I..L........ :sl..: `�. C J7G SEPTIC SYSTEM MUST BE '. INSTALLED IN COMPLIANCE Sewage Permit number ... -... �� ....... .. } WITH ARTICLE II STATE Y SA;`•!ITARY CODE AND TOWN C °f��Ero�� t. TOWN OF BAR. OAMLE i BAHBSTAIM'.I Ci "6 q �� �' 131I�wLDING INSPECTOR o �0 4 . 0 VA * APPLICATION FOR,--'PERMIT TO .. TYPE OF CONSTRUCTION ...... ...... .... y '' r.®.....................9.. k TO THE INSPECTOR OF BUILDINGS: The undersigned hereby'applies for a permit acco ding to the following information: ty Location ............... . .. .............................................................................................................................................................. Proposed Use ... .................................................................................................01 ..................... Zoning District ............................��. Fire District .................... . Name of Owner .. .. .......... ........................Address ....�1... ...................................:. . . .................................. • Address CC - ..`�.Name of Builder ..F......(3........n�.p. .R ..................... J�..o................... Nameof Architect :..... ............ ....Address ...........e. .......... ............................................................................ Numberof Rooms ..................................................................Foundation ...... .... ......................................... Exterior ...... ..... ................ .. ........`.... .......,..:...........:...........Roofing ..... ..................... Floors7 ............................Interior ................ 4....................................................... ............ r Heating �i!t ►r`�..................:......................Plumbing ................. ......................................................:.... ev Fireplace ..................................................................................Approximate Cost ........ 6 ......................................... . Definitive Plan Approved by Planning Board ___________________________ -----19--------. Area ....i?. .............. Diagram of Lot and Building with Dimensions _ Fee C) ~� SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules 'and Regulations of the°Town of Barnstable regarding the above construction. Name .... . ........ ..... .......... Coop, Fern 18647 add to dwelling No ................. Permit for .................................... r ............................................................................... I 53 Greenwood Svenue Location .......................................... Hyannis . ............................................................................... Owner .............Fern ................Cookern F .......................................... Type of-:Construction ..................................frame ......... . ................ ............................................. .................. Plot ............................ Lot ................................. September 10 76 .......................... e ........19 _Wmit Granted ...... Date of In/spection ............... ...................19 —Date 'Completed .................19 'PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... .................. ..... ........................................................ Approved ................................................ 19 ............................................................................... ............................................................................... LlAssessor's map and lot number .......'1..... ?K. .�..L. .. (� Sewage Permit number ..`":.............y...�........r:....`t. .,: .:.... TOWN OF BARNSTAEL•E THE to Z BARNSTODLE, i "b 9 BUILDING INSPECTOR c ° o�aYa�e x Y APPLICATION FOR4 PERMIT TO .....( .... .. ! ... L !. . ,'.�4 ..... ..!............. TYPE OF CONSTRUCTION ...... '...ls� � `�,, .'� .:r 'E1�:........'. c t .................................. 19 r i ........... .............................. ........ r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location J ...a,.- . ProposedUse :.....................`:.'.:r..... ...•...�J�. .......... .................................................................................................. ZoningDistrict ............................. ..:.:.................................Fire District ..........:...R.... ................................................. Name of Owner L 0 U Address ....` .. ,. ......... ................................................ ......................................^.............................. Nameof Builder .•...... ........�. ..... 3 ......................Address ..-'.. .......... ............t:..�...... ....................................... Name of Architect .......r''' ........................................Address � ~ Numberof Rooms ..................................................................Foundation ............................................:.....::.......................... Exlerior ........A ,'?`?` � ... ........................".....5..'.'`'�"......�....:............................Roofing .... --a : ................ Floors t` ........a.......................Interior .......YA, Heating r:' .t: �- Plumbing �'u�.{h+�A•......... ..... '... .............. .................4 .............................................I............. Fireplace ................r.......`..................................4......................Approximate Cost ........a�:. ........................................................ ........................... Definitive Plan Approved by Planning Board --------------------------------19--------. ' Area .... ..t................. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .......... .... • it ` �. Cook, Fern A=289-94 No 18647 Permit for .. add to in e 17.......... ............... ............. ....s.... ........... family-dwelling ............................................................ . ................ 53 Greenwood Ave ue Location ................................................................ Hyannis ............................................................................... Fern Cook Owner .................................................................. Type of Construction ..........frame....................... ....................................... .................................... Plot ............................ W ................................ temb r 10 76 %. rmit Granted ..... ....... ......... ...............19 Date of Inspection .... ...............................19 Date Completed .......... ...........................19 PERMIT REFUSED ................................................... ............ 19 .. .. . ................ ........ ....................... ........................................................;...................... .................. ........................................................... Approved ................................................ 19 .......... .................................................................... Ar'l Assessor's office(1st Floor): Assessor's map and lot number of TMt r Conservation(4th Floor): Board of Health(3rd floor): • Sewage Permit number sasry ant Engineering Department(3rd floor): _ oo�t6}9•``,� House number 6 air Definitive Plan Approved by Planning Board 19 APPLICATIONS PROCESSED 8:30-9:30 A.M.'and 1:00-2:00 P.M.only TOWN ' O,F BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION i 19� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for /a`permit according to the following information: Location I Proposed Use S i Gf f nI.a C Zoning District r I�I Fire District '1T1U�1� Name of OwnerVL(411 Address . 3 C�R �i1C.✓C)c� �}c Name of Builder Address Name of Architect Address Number of Rooms ) - Foundation_�� .��C— Exterior RoofingkJ V s A Floors Interior Heating �y Plumbing Fireplace / Approximate Cost ow- Area Diagram of Lot and Building with Dimensions Fee © OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. t. Construction Si ipervisor's License Est BARRETT, JUDITH ' No Permit For INSTALL i -WINDOWS AND DOORS Location 53 Greenwood Ave. Hyannis Owner, Judith":"-M. Barrett r 4 Type of Construction - Plot Lot Permit Granted August 9, 19 94 , Date of Inspection: _ Frame 19 Insulation 19 `- = Fireplace 19 Date Completed _- 19 • 4 r r TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. DATE 8' JOB LOCATION _ IAJ U c) Number Street Address / Section Of -Town "HOMEOWNER" Name Home Phone Work Phone PRESENT MAILING ADDRESS /9"A a /31 City/Town State Zip Code The current exemption for "homeowners" was extended to include..owner-. occupied dwellings of six units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner- acts as supervisor. DEFINITION OF HOMEOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one to six family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building Permit. (Section 109.1.1) The undersigned "homeowner" assumes responsibility for compliance with the .. State Building Code and other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements HOMEOWNER'S SIGNATUR � l APPROVAL OF BUILDI OFFICIAL Note: Three family dwellings 35,000 cubic feet, or 'larger, will be required to comply with State Building Code Section 127.0, Construction Control. < MISCS r HOME OWNER'S EXEMPTION The code states that: "Any Home Owner performing work for which permit is required shall be exempt. from the provisions of this section r (Section 109. 1. 1 - Licensing of Construction Supervisors Home Owner engages a person(s) for hire to do such is taon Owner shall act as supervisor. " ) % provided that if k, that such Home Many Home Owners who use this exemption are unaware that the responsibilities of a supervisor (see A 4 Appendix they are assuming. for Licensing Construction Supervisors, Section 2.1 , •Rules and Regulations awareness. often results in serious problems This lack of -Owner hires unlicensed persons. Particularly when the Home against the unlicensed erson as it would cwith ase olicensed ur Board cannotsupervisor. Home Owner acting as supervisor is ultimately responsible. proceed pervisor. The To ensure that the Home Owner is fully aware of his/her res onsib'l ies, many communities require, as part of the permit application, that the Owner certify that he/she understands the responsibilities of a On the last page of this issue is a form currently used b severalHome You may care to amend and adopt such a form/certifi supervisor. community. cationyfor useinoyour COMMONWEALTH OF MASSACHUSETTS =F '� DE`AIUMENI' OF INDUSTRIAL ACCIDENT'S 600 WASHINGTON STREEt BOSTON, NLkSSACHUSETI'S 02111 fames Gamaoei' �rsstone, WORKERS' COMPENSATION INSURANCE AFFIDAVIT (licensee/permiacc) with a principal place of business/residence at: (City/State/Zip) do hereby certify, under the pains and penalties of perjury, that. ( J 1 am an employer providing the following workers' compensation coverage for my employees working on this job. A - . Insurance Company Policy Number [ � I am a sole proprietor and have no one working for me. [ J I am a sole proprietor, general contractor or homeowner (circle one) and have hired the contractors listed below who have the following workers' compensation insurance policies: Name of Contractor Insurance Company/Policy Number Dame of Contractor Insance Company/Policy Number ur Name of Contractor Insurance Company/Policy Number. J� I am a homeowner performing all the work myself. ` NOTE: Plcasc be aware that while bomeowncrs who employ persons to do maintenance,construction or repair work on a dwelling of not more than tbrec units in wbicb the homeowner also resides or on the grounds appurtenant thereto arc not generally considered to be employers under the Workers' Compensation Act(GL C. 152,sect. 1(5)), application by a bomeowner for a license or permit may evidcncc the legal sutus of an employer under the Workers' Compensation ACL 1 understand that a copy of this statement will be forwarded to the Department of Industrial Accidents'Office of Insurance for coverage verifJcation and that failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of_g-,dminal penalties consisting of a fine of up to S1500.00 and/or imprisonment of up to one year and civil penalties in the form of a Stop Work Order and a, fine of$100.00 a day against me. Si ed this day of , 19 Licensee/Permirtce Licensor/Permittor